Choice A rationale:

A flat, nonpalpable, dark-colored area of skin on the trunk is likely a benign nevus, or mole, that does not pose a serious threat.

Choice B rationale:

An atrophic wart on the left index finger is also a benign growth that can be removed by cryotherapy or surgery.

Choice C rationale:

Skin tags in the nose region are harmless skin protrusions that are common in older adults and can be removed for cosmetic reasons.

Choice D rationale:

The nurse's priority is to assess the mole on the shoulder that has changed in appearance. This could indicate a malignant melanoma, which is a type of skin cancer that can spread quickly and be fatal.

Choice A rationale:

Placing an oval corn pad over toes and removing it weekly may increase the risk of infection and skin breakdown. Continuous use of pads can trap moisture, potentially leading to complications for individuals with diabetes.

Choice B rationale:

Applying lotion to soften calluses without putting lotion between the toes is correct. Moisturizing can help prevent dry skin, but it's essential to avoid moisture between the toes to prevent fungal infections. The emphasis on proper foot care aligns with diabetes management, where foot health is crucial.

Choice C rationale:

Using over-the-counter liquid medication to remove corns without professional guidance can lead to complications and skin damage. It's important to involve healthcare providers in the management of foot issues in individuals with diabetes.

Choice D rationale:

Soaking feet in warm water daily can contribute to moisture, increasing the risk of fungal infections. It's generally not recommended for individuals with diabetes, emphasizing the importance of avoiding excessive moisture.

Choice A rationale:

Determining whether the client can afford the insulin administration supplies is a priority to ensure that the client can effectively manage their diabetes.

Access to supplies is crucial for adherence to the treatment plan. Financial considerations directly impact the client's ability to follow through with prescribed treatments.

Choice B rationale:

Providing the client with the contact number for a diabetes education specialist is important but is a subsequent step after addressing the immediate concern of affordability.

Choice C rationale:

Making a copy of the medication reconciliation form is a part of the documentation process but is not the first priority. While documentation is essential, addressing immediate needs takes precedence.

Choice D rationale:

Obtaining printed information about insulin self-administration is important, but assessing affordability comes first to ensure the client can implement the education received. Understanding the client's financial capacity is foundational to effective diabetes management.

Choice A rationale:

The infant's provider does not sign the consent form. The legal guardian or parent typically provides consent for a minor's surgery.

Choice B rationale:

The infant's 17-year-old mother is likely the legal guardian and can provide consent for the infant's surgery. According to the law, a minor who becomes a parent can consent to medical care for themselves and their child, regardless of their age. Therefore, the infant's mother, even though she is 17 years old, can sign the consent form for her infant's surgery. Legal guardianship is crucial for obtaining valid consent for a minor's medical procedure.

Choice C rationale:

The mother's 21-year-old sibling is not the legal guardian unless legally designated as such. Consent from a legal guardian or parent is essential for pediatric procedures.

Choice D rationale:

The grandparent is not typically the legal guardian unless legally designated as such. Consent from the legal guardian or parent is required for surgical procedures involving minors.

Choice A rationale:

Hyperextending the client's back is not necessary and may cause discomfort or harm. Proper positioning is essential for the client's comfort and safety.

Choice B rationale:

Encouraging the client to try to defecate for an extended period may lead to unnecessary strain and discomfort. It's important to promote optimal conditions for toileting without excessive strain.

Choice C rationale:

Keeping the bed flat while the client is on the fracture pan is a correct action. Maintaining the bed's flat position facilitates proper use of the fracture pan and enhances the client's comfort.

Choice D rationale:

Placing the shallow end of the fracture pan under the client's buttocks is the correct way to position the pan for effective use. Proper use of the fracture pan is essential for its intended function in clients with immobility or limited mobility due to a cast.

Choice A rationale:

Holding the breath during Kegel exercises is not recommended. Clients should maintain regular breathing patterns during these exercises.

Choice B rationale:

Tightening the buttocks is not the focus of Kegel exercises. The emphasis is on contracting the pelvic muscles.

Choice C rationale:

Expecting improvement after 2 weeks may not be realistic. Improvement in urinary incontinence from Kegel exercises can vary among individuals, and consistency over a more extended period is often necessary.

Choice D rationale:

Contracting the pelvic muscles is the correct instruction for Kegel exercises. These exercises aim to strengthen the pelvic floor muscles, which can help prevent or manage urinary incontinence.

Choice A rationale:

The radial vein on the left wrist is not typically chosen for IV therapy. Additionally, proximity to the mastectomy site may be a consideration.

Choice B rationale:

The cephalic vein on the back of the right hand is not typically selected, especially following a right mastectomy. Choosing a vein on the affected side may increase the risk of complications.

Choice C rationale:

The cephalic vein in the left distal forearm is a suitable choice. It is on the opposite side of the mastectomy and allows for effective IV therapy.

Choice D rationale:

The basilic vein in the right antecubital fossa is on the affected side and may pose a higher risk of complications. Choosing a vein on the opposite side is generally preferred.

Choice A rationale:

Having an implanted defibrillator is a contraindication for magnet therapy. Magnets can interfere with the functioning of electronic devices, such as defibrillators.

Choice B rationale:

Metoprolol is a beta-blocker and does not pose a contraindication for magnet therapy.

Choice C rationale:

A history of alcohol use disorder is not a contraindication for magnet therapy.

Choice D rationale:

Allergies to penicillin are not relevant to the use of magnet therapy.

Choice A rationale:
Delirium can affect a client's sleep cycle, often causing disturbances in sleep-wake patterns.

Choice B rationale:
Delirium typically has a rapid onset, not a slow progression.

Choice C rationale:
The correct statement is that delirium has an abrupt onset. Understanding this characteristic helps nurses recognize and address delirium promptly.

Choice D rationale:
Delirium can significantly impact a client's perception of the environment, leading to confusion and disorientation.

Choice A rationale:

Choosing the most proximal site on the extremity is not recommended. Peripheral IV catheters are typically inserted in more distal sites to preserve more proximal sites for other needs.

Choice B rationale:

the nurse should place the extremity in an elevated position, to reduce blood flow and make the veins more visible.

Choice C rationale:

Placing the tourniquet above the proposed insertion site is the correct action. This helps distend the veins, making them more visible and accessible for insertion by occluding venous return thus engorging the vein.

Choice D rationale:

Applying a cool compress is not a standard practice before IV catheter insertion. Warm compresses may be used to enhance vein visibility.

Choice A rationale:

Applying a bath blanket between the client and a cooling blanket helps prevent direct contact, reducing the risk of chilling or discomfort. This method facilitates gradual cooling in cases of high fever.

Choice B rationale:

Covering the client with heavy blankets after shivering subsides is not appropriate during active cooling efforts for a high fever.

Choice C rationale:

Placing ice packs on the neck and behind the knees can be too aggressive and may lead to vasoconstriction, limiting the effectiveness of heat dissipation.

Choice D rationale:

Giving a sponge bath with an alcohol-water solution is not recommended, as alcohol can lead to skin dryness and increased heat loss.

Choice A rationale:

Telling the client's visitors to wear a mask within 3 feet is not a standard precaution for MRSA. Standard precautions, including hand hygiene, are generally sufficient.

Choice B rationale:

Placing the client in a private room is appropriate to prevent the spread of MRSA to other clients.

Choice C rationale:

Wearing an N95 respirator mask is not necessary for routine care of a client with MRSA. Standard precautions are usually adequate.

Choice D rationale:

Removing the gown before gloves is not consistent with standard precautions. The gown should be removed after gloves to minimize the risk of contamination.

Choice A rationale:

this is not enough to prevent clogging and ensure adequate hydration.

Choice B rationale:

Combining medications with the formula in the feeding bag may alter the absorption and effectiveness of the medications.

Choice C rationale:

Diluting crushed medications with sterile water individually ensures accurate dosing and avoids potential interactions.

Choice D rationale:

Mixing medications in a single syringe may cause interactions between medications and compromise accurate dosing while preventing obstruction.

Choice A rationale:

The statement is not accurate. Signing advance directives is typically voluntary, and it is the client's decision.

Choice B rationale:

Providing written information about advance directives before signing allows the client to make an informed decision about their preferences for care.

Choice C rationale:

The provider's signature is not required for the client to complete advance directives.

Choice D rationale:

The partner's presence is not mandatory when signing advance directives. It is a personal decision made by the client.

Choice A rationale:

Tying restraints to the side rail is unsafe and increases the risk of injury. Restraints should be attached to the bed frame, not the side rails.

Choice B rationale:

Removing the restraints every 3 hr is not enough to prevent complications such as skin breakdown, nerve damage, or circulation impairment.

Choice C rationale:

Securing restraints with a square knot can make it difficult to release them quickly in an emergency.

Choice D rationale:

Removing one restraint at a time allows the nurse to assess the client's behavior and readiness for restraint removal, as well as to provide care and comfort.

Choice A rationale:

Documenting the fluid infusion in the client's chart is important but is not the first action to address the immediate concern.

Choice B rationale:

Reporting the incident to the unit manager can be done after taking immediate actions to address the client's well-being.

Choice C rationale:

Completing an incident report is necessary but is not the priority when the client's health is at risk.

Choice D rationale:

Obtaining the client's vital signs is the first action to assess the client's response to the inadvertent administration of a larger fluid bolus, as it helps in identifying any potential complications.

Choice A rationale:

Having a fire escape plan is an essential aspect of home safety.

Choice B rationale:

Setting the hot water heater to 140 degrees Fahrenheit is too high and can cause burns. Therefore, this statement indicates a misunderstanding.

Choice C rationale:

Applying tape over frayed areas of electrical cords is unsafe and can lead to electrical hazards. Therefore, this statement indicates a misunderstanding.

Choice D rationale:

Using grab bars when getting in and out of the bathtub promotes safety and prevents falls.

Choice E rationale:

Checking medications for expiration dates is crucial to ensure their effectiveness and safety.

Choice A rationale:

Referring the client to a breast cancer support group is a helpful intervention, but it may not be the first action.

Choice B rationale:

Providing the client with a mirror to look at her mastectomy incisions may be done later in the healing process.

Choice C rationale:

Identifying the impact of the mastectomy on the client's body image is the first action to address the client's emotional needs and concerns.

Choice D rationale:

Encouraging the client to assist with her dressing changes may be appropriate but does not address the emotional aspect of the client's response.

Choice A rationale:

Providing brochures about the procedure may be helpful, but the immediate concern is the client's expressed lack of understanding.

Choice B rationale:

Notifying the provider is the first action to address the client's concerns and ensure that the client has a clear understanding of the surgery. The nurse should also document the client's statement and the provider's response in the medical record.

Choice C rationale:

Describing the surgery to the client is important, but the provider should be informed first to address the client's immediate concerns.

Choice D rationale:

Completing an incident report is not applicable in this context, as it involves a communication issue rather than an incident.

Choice A rationale:

Unplugging the pump is the first action to eliminate the immediate risk of sparks and prevent potential electrical hazards.

Choice B rationale:

Notifying the biomedical department is important but should be done after ensuring the immediate safety of the client.

Choice C rationale:

Labeling the pump with a defective equipment sticker is appropriate but does not address the immediate risk.

Choice D rationale:

Obtaining a replacement pump is a reasonable step, but unplugging the malfunctioning pump takes precedence to prevent any electrical hazards.

Choice A rationale:

This will reduce splashing and aerosolization of the solution. This prevents contamination of the solution and the sterile field by keeping a safe distance from the bowl.

Choice B rationale:

Sterile gloves should be applied after the sterile field is established to prevent contamination. This will prevent contamination of the gloves by touching the outside of the bottle.

Choice C rationale:

the nurse should place the lid of the sterile solution bottle face up on a separate sterile drape, not face down on the same drape. This will prevent contamination of the lid and the drape by touching each other.

Choice D rationale:

the nurse should hold the bottle of sterile solution so that the label is facing away from the palm of the hand, not towards it. This will prevent the label from getting wet and unreadable.

Choice A rationale:

Laughing at a television show is not a direct indicator of the effectiveness of the warm, moist compress in relieving lower back pain.

Choice B rationale:

Intact skin on the lower back without redness indicates that the compress has been effective in preventing skin damage or irritation.

Choice C rationale:

The ability to concentrate while reading may not be a specific indicator of the effectiveness of the warm compress in relieving lower back pain.

Choice D rationale:

Vital signs within the expected reference range are important but do not directly reflect the effectiveness of the warm compress in relieving pain.

Choice A rationale:

This response is correct. ALT (alanine aminotransferase) is an enzyme found in the liver. An elevated ALT level may indicate liver damage or disease.

Choice B rationale:

ALT is not specific to kidney function.

Choice C rationale:

ALT does not provide information about heart function.

Choice D rationale:

ALT is not associated with the risk of developing blood clots.

Choice A rationale:

Checking for areas of tenderness helps to identify any inflammation, infection, or injury in the abdominal cavity.

Choice B rationale:

Listening to the abdominal arteries helps to detect any bruits or abnormal sounds that may indicate vascular problems.

Choice C rationale:

Providing adequate lighting allows the nurse to inspect the abdomen for any abnormalities, such as distension, scars, or lesions.

Choice D rationale:

Percussing the abdomen helps to assess the size and density of the organs, as well as to detect any fluid or gas accumulation.

Choice E rationale:

Locating the liver and spleen borders helps to determine if they are enlarged or displaced.

Choice A rationale:

Cool skin is not indicative of hyperglycemia. In hyperglycemia, the skin may be warm or normal.

Choice B rationale:

Shakiness is more associated with hypoglycemia (low blood glucose) rather than hyperglycemia.

Choice C rationale:

Confusion can be seen in both hyperglycemia and hypoglycemia, but it is not specific to hyperglycemia.

Choice D rationale:

Thirst is a common symptom of hyperglycemia. High blood glucose levels lead to increased thirst as the body tries to dilute excess glucose in the blood by drawing in more water.

Choice A rationale:

Verifying the count total after removing the required amount is a step in ensuring accurate medication administration, but it is not specifically related to controlled substances.

Choice B rationale:

Asking a second nurse to record her signature is a recommended practice when wasting any unused portion of a controlled substance to ensure accountability.

Choice C rationale:

Reporting any discrepancy in the count total is essential, especially for controlled substances, to maintain accuracy and detect potential diversion.

Choice D rationale:

Placing the wasted portion in the sharps container is not the correct disposal method for controlled substances. Controlled substances should be witnessed and documented during disposal.

Choice A rationale:

Nighttime urinary incontinence can occur in older adults but is not a universal finding.

Choice B rationale:

Decreased sense of balance is a common age-related change in older adults and can contribute to an increased risk of falls.

Choice C rationale:

Older adults may have a decreased, rather than heightened, sense of pain due to various factors.

Choice D rationale:

Increased nighttime sleeping is not a typical finding in older adults and can vary among individuals.

Choice A rationale:

Room number is not a specific client identifier and does not ensure accurate identification.

Choice B rationale:

Age is not a unique identifier and may not differentiate between clients with the same age.

Choice C rationale:

Bed number alone is not sufficient for accurate client identification.

Choice D rationale:

A photograph is a reliable client identifier and ensures accurate identification before administering medication or performing procedures.

Choice A rationale:

Recapping the needle before disposal is not recommended due to the risk of needlestick injuries.

Choice B rationale:

Placing the needle on the bedside table poses a safety risk and is not an appropriate action.

Choice C rationale:

Discarding the needle in a puncture-proof container is the correct action for safe disposal.

Choice D rationale:

Removing the needle from the syringe may be necessary for disposal but should be done carefully and in accordance with safety protocols.

Choice A rationale:

Performing a simple dressing change is a task that can be delegated to assistive personnel.

Choice B rationale:

Evaluating the healing of an incision requires nursing judgment and assessment skills, making it more appropriate for the nurse to perform.

Choice C rationale:

Inserting an NG tube is a complex procedure that requires specific nursing skills and should not be delegated to assistive personnel.

Choice D rationale:

Changing IV tubing involves critical steps and should be performed by the nurse to ensure patient safety.

Choice A rationale:

Developing a plan for integrating the change into the client's lifestyle is more applicable to the preparation stage. During contemplation, the focus is on recognizing the need for change.

Choice B rationale:

Recommending small changes is more aligned with the preparation stage when the client is ready to take action.

Choice C rationale:

Presenting information about the benefits of quitting smoking is more suited for the precontemplation or contemplation stage when the client is still considering the need for change.

Choice D rationale:

Assisting the client in setting goals to make the change is appropriate for the contemplation stage. This involves helping the client explore options and make decisions about behavior change.

Choice A rationale:

Keeping legs crossed while sitting can contribute to venous stasis and thrombus formation and is not a recommended practice.

Choice B rationale:

Limiting the time spent sitting in a chair is a preventive measure to reduce the risk of thrombus formation.

Choice C rationale:

Performing leg exercises regularly, at least once every 1-2 hours, is beneficial in preventing thrombus formation.

Choice D rationale:

Massaging the legs when they hurt is not a primary prevention measure for thrombus formation and may not be sufficient in preventing complications.

Choice A rationale:

This response does not directly address the client's expressed worry and may not provide reassurance.

Choice B rationale:

Acknowledging the client's worry about the colostomy is a therapeutic response that opens the door for further discussion.

Choice C rationale:

Deferring the discussion until after the surgery may increase the client's anxiety. Providing information and addressing concerns preoperatively is essential for emotional preparation.

Choice D rationale:

Asking about the client's experience with others who have a colostomy is a way to explore the client's knowledge and feelings but does not directly address the expressed worry.

Choice A rationale:

Threatening to place the client in restraints without proper justification constitutes false imprisonment, which involves restricting a person's freedom without legal authority.

Choice B rationale:

Assault involves the threat of bodily harm, but the situation described is more consistent with false imprisonment.

Choice C rationale:

Defamation of character involves making false statements about a person, which is not applicable in this scenario.

Choice D rationale:

Battery involves the intentional touching of another person without their consent, which is not described in this situation.

Choice A rationale:

Emptying the drainage bag when it is three-quarters full helps prevent urinary stasis and potential infections.

Choice B rationale:

Taping the catheter to the lower abdomen is not a recommended practice and may cause trauma to the catheter site.

Choice C rationale:

Keeping the drainage bag below the level of the bladder ensures continuous drainage and prevents urine reflux into the bladder.

Choice D rationale:

Attaching the drainage bag to the side rails of the bed is not appropriate, as it may impede proper drainage and increase the risk of infection.

Choice A rationale:

"SS" for sliding scale could be misinterpreted as "sugar solution" or "single strength," leading to confusion. It is better to write out "sliding scale" for clarity.

Choice B rationale:

"BRP" for bathroom privileges is not an acceptable abbreviation commonly used in healthcare documentation.

Choice C rationale:

"OJ" for orange juice could be confused with "oj" for "ojus," a term used in some cultures for clarified butter. Using "orange juice" is clearer.

Choice D rationale:

"SQ" for subcutaneous is an acceptable abbreviation commonly used in healthcare documentation.

Choice A rationale:

A blood glucose level of 110 mg/dL is within the normal range and is an expected finding.

Choice B rationale:

A weight gain of 0.91 kg (2 lb) in 2 days could be expected in a client receiving enteral feeding due to fluid intake. However, it's important to monitor for signs of fluid overload.

Choice C rationale:

Diarrhea one time in a 24-hour period can occur in some clients but should be monitored for any patterns or changes.

Choice D rationale:

A gastric residual of 300 mL at the end of the shift is higher than expected and may indicate delayed gastric emptying or intolerance to enteral feeding. This finding should be reported.

Choice A rationale:

Performing percussion over the lower back is appropriate during postural drainage for a client with cystic fibrosis to help loosen and mobilize secretions.

Choice B rationale:

Covering the area of percussion with a towel can help protect the skin and provide comfort during the procedure.

Choice Crationale:

Scheduling postural drainage after meals is not recommended, as it may increase the risk of vomiting and aspiration. It is better to schedule the procedure before meals or 1-2 hours after meals.

Choice Drationale:

Instructing the client to exhale quickly during vibration can enhance the effectiveness of the therapy.

Choice A rationale:

A calcium level of 9.6 mg/dL is within the normal range.

Choice B rationale:

A potassium level of 5.8 mEq/L is elevated and should be reported to the provider.

Choice C rationale:

A magnesium level of 1.9 mEq/L is below the normal range and should be reported to the provider.

Choice D rationale:

A sodium level of 140 mEq/L is within the normal range.

Choice A rationale:

Ensuring the gloves in the surgical suite are powdered is not appropriate, as latex gloves with powder can aerosolize latex proteins, increasing the risk of an allergic reaction. Powder-free gloves should be used.

Choice B rationale:

Cleaning stoppers with povidone-iodine is not directly related to latex allergy and may not be necessary in the context of latex allergy.

Choice C rationale:

Scheduling the client as the first surgical procedure of the day is appropriate to minimize the client's exposure to latex in the environment.

Choice D rationale:

Removing stopcocks from IV tubing is not a standard precaution for latex allergy and may not be necessary in all cases. Minimizing latex exposure in the surgical suite is a more comprehensive approach.

Choice A rationale:

Tuberculosis is transmitted via airborne droplets, so airborne precautions are necessary. The nurse should wear an N95 respirator mask when caring for the client, and the client should be placed in a negative pressure room. Airborne precautions include wearing a respirator mask, placing the client in a negative pressure room, and limiting the movement of the client outside the room.

Choice B rationale:

Droplet precautions are used for infections that are spread by large respiratory droplets, such as influenza or pertussis.

Choice C rationale:

Contact precautions are used for infections that are spread by direct or indirect contact with the client or their environment, such as scabies or Clostridium difficile.

Choice D rationale:

Protective precautions are used for clients who are immunocompromised and at risk of infection from others, such as those who have had a stem cell transplant or chemotherapy.

Choice A rationale:

Inserting a glycerin suppository involves a sterile procedure, and it is typically performed by licensed nursing personnel, not assistive personnel.

Choice B rationale:

Assisting with ambulation for a client with a pulmonary infection is within the scope of practice for assistive personnel. They can help with mobility and activities of daily living.

Choice C rationale:

Irrigating a client's infected surgical wound requires skill and knowledge to prevent infection and promote healing. This task is typically performed by licensed nursing personnel.

Choice D rationale:

Showing a client how to use an incentive spirometer involves education and is best done by licensed nursing personnel.

Choice A rationale:

An oral airway can be used to maintain an open airway during and after a seizure.

Choice B rationale:

Oral suction equipment is needed to clear the airway of any secretions or fluids after a seizure.

Choice C rationale:

Limb restraints are not typically used in seizure precautions. The focus is on ensuring a safe environment and protecting the client from injury.

Choice D rationale:

A blood glucose monitor is not directly related to seizure precautions.

Choice E rationale:

Supplemental oxygen supplies are not specific to seizure precautions, but providing oxygen may be necessary based on the client's overall condition and response to the seizure.

Choice A rationale:

Having the client nod to indicate understanding may not be sufficient, especially when dealing with complex medical information. It's essential to ensure clear communication, which is best achieved with the assistance of an interpreter.

Choice B rationale:

Recommending an interpreter who is the same gender as the client is a culturally sensitive approach. It ensures the client's comfort and enhances effective communication during the consent process.

Choice C rationale:

Addressing all questions to the interpreter may hinder the direct communication between the nurse and the client. It's crucial to involve the client in the discussion to understand their concerns and provide appropriate information.

Choice D rationale:

Using medical terminology when explaining the procedure might lead to misunderstandings, especially if the client is not familiar with the terminology. Clear, simple language is essential for effective communication.

Choice A rationale:

Applesauce is not typically considered a full liquid. It has a thicker consistency, and full liquid diets usually include clear liquids and foods that are liquid at room temperature.

Choice B rationale:

Oatmeal is not part of a full liquid diet. It has a solid consistency and is not in a liquid or semi-liquid form.

Choice C rationale:

Scrambled eggs are not included in a full liquid diet. They are a solid food and are not in a liquid or semi-liquid form.

Choice D rationale:

Plain yogurt is appropriate for a full liquid diet. It meets the criteria of being in a liquid or semi-liquid form at room or body temperature.

Choice A rationale:

Assuring the client that the provider will come to talk to him when she gets the chance may create uncertainty for the client. It's essential to address the client's concerns promptly.

Choice B rationale:

Explaining that the client should trust the provider because she has an excellent reputation does not directly address the client's specific questions about the treatment plan and discharge.

Choice C rationale:

Informing the provider that the client is requesting information about his treatment plan is the appropriate action. It facilitates communication between the client and the provider, ensuring that the client receives the necessary information about postoperative care and discharge planning.

Choice D rationale:

Telling the client that the provider will discharge him when she feels he is ready to leave does not provide the client with the information he is seeking. It is essential to address the client's concerns and provide relevant information.

Choice A rationale:

This statement is objective and factual statements that do not require documentation.

Choice B rationale:

This statement is objective and factual statements that do not require documentation. Furthermore, this statement is already recorded in the medication administration record

Choice C rationale:

This statement is objective and factual statements that do not require documentation.

Choice D rationale:

The wound seems clean and does not appear to be infected. This entry by the nurse requires documentation because it is a subjective assessment of the wound condition, which may not be accurate or consistent with other observations.

Choice A rationale:

the nurse should hold the vial upside down and insert the needle into the center of the rubber stopper.

Choice B rationale:

Holding the syringe at a 45° angle to verify dosage is not a standard practice during the preparation of medication from a vial. The syringe should be held upright at 90° to accurately measure the desired dosage.

Choice C rationale:

Holding the syringe so that bubbles collect at the level of the plunger is incorrect. The nurse should hold the syringe so that bubbles collect at the level of the needle tip. Bubbles should be expelled from the syringe before withdrawing the medication to ensure accurate dosage.

Choice D rationale:

Injecting air into the vial with the eye of the needle immersed in the fluid is correct. This action prevents the formation of bubbles and ensures accurate dosage.

Choice A rationale:

Assessing comfort level is important, but assessing peripheral pulses takes precedence to ensure the client's safety and prevent complications.

Choice B rationale:

Assessing skin integrity is relevant but secondary to assessing peripheral pulses. Skin integrity can be addressed after ensuring adequate circulation.

Choice C rationale:

Assessing elimination needs is not the priority in this context. While it's important to address overall care needs, assessing peripheral pulses is more critical in preventing complications related to restraints.

Choice D rationale:

Assessing peripheral pulses is the priority when caring for a client with restraints to each extremity. Monitoring circulation ensures that blood flow is maintained, and complications related to impaired circulation are promptly identified.

Choice A rationale:

Helping the client find a local support group is an appropriate intervention. Support groups provide emotional support, shared experiences, and coping strategies for individuals facing terminal illness, promoting a sense of community.

Choice B rationale:

Discussing the client's prior coping mechanisms is relevant and can provide insight into effective strategies. However, it might not be the first step in the immediate response to a new diagnosis of terminal cancer.

Choice C rationale:

Developing a list of goals with the client might be premature at this stage, as the client may need time to process the diagnosis and express their concerns and priorities.

Choice D rationale:

Teaching the client to use progressive relaxation techniques is a valuable intervention for managing anxiety and promoting relaxation. However, immediate emotional support and connection through a support group may be more appropriate initially.

Choice A rationale:

Determining areas of resonance across the abdomen can help evaluate for gas accumulation, but it is not as sensitive as visual inspection.

Choice B rationale:

Listening for bowel sounds can help assess for bowel function, but it is not reliable in detecting complications.

Choice C rationale:

The nurse should first expose the client's abdomen to look for changes in appearance. This is because sudden, severe abdominal pain after bowel resection could indicate a complication such as anastomotic leak, bowel perforation, or internal bleeding. These conditions can cause signs of peritonitis, such as abdominal distension, rigidity, or bruising. By visually inspecting the abdomen, the nurse can quickly assess for these signs and initiate appropriate interventions.

Choice D rationale:

Performing abdominal palpation can help identify areas of tenderness or masses, but it can also cause pain and discomfort to the client and increase the risk of infection.

Choice A rationale:

Drawing the short-acting insulin into the syringe comes after injecting air into the vial.

Choice B rationale:

Injecting air into the short-acting insulin vial is the first step when mixing short-acting and intermediate-acting insulins in the same syringe. This step prevents creating a vacuum in the vial, facilitating the withdrawal of the correct dose.

Choice C rationale:

Drawing the intermediate-acting insulin into the syringe is the final step in the process.

Choice D rationale:

Injecting air into the intermediate-acting insulin vial is the next step after preparing the short-acting insulin.

Choice A rationale:

Administering oral contrast before the procedure is not a standard preparation for an intravenous pyelogram, which primarily involves imaging of the urinary system.

Choice B rationale:

Ensuring the client is free of metal objects is important for tests that use magnetic fields, such as MRI or CT scan, but not for an intravenous pyelogram.

Choice C rationale:

Monitoring the client for pain in the suprapubic region is relevant post-procedure but is not a pre-procedural action. Monitoring the client for pain in the suprapubic region is not a specific action for this test, as pain may occur in any part of the urinary tract due to the contrast dye.

Choice D rationale:

An intravenous pyelogram is a diagnostic test that uses an injection of contrast dye to visualize the kidneys, ureters, and bladder. Bowel cleansing prevents interference with the visualization of the urinary tract. The contrast dye may cause constipation, so the client needs to have a bowel cleansing before the procedure to prevent complications.

Choice A rationale:

Using a cotton tip applicator to clean inside the inner cannula can cause cotton fibers to be dislodged and enter the trachea, posing a risk of aspiration.

Choice B rationale:

Cleansing the skin around the stoma with normal saline is an appropriate action for a client with a tracheostomy. This helps maintain skin integrity and prevent infection.

Choice C rationale:

Soaking the outer cannula in warm, soapy tap water is not a recommended practice. It may compromise the integrity of the tracheostomy equipment.

Choice D rationale:

Securing the tracheostomy ties to allow one finger to fit snugly underneath is a guideline for securing ties at the correct tightness to prevent complications. However, it is not a cleaning action.

Choice A rationale:

The client's age is not a part of the measurement in the Braden scale.

Choice B rationale:

Each element in the Braden scale has a range from one to four points, except for friction and shear, which is scored from one to three points.

Choice C rationale:

The lower the score, the higher the risk of developing pressure injuries.

Choice D rationale:

The Braden scale is a tool that helps nurses assess the risk of developing pressure injuries in clients. It consists of six elements: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

Choice A rationale:

Scheduling a support session for the client is important for emotional support but is not the priority before addressing the client's immediate communication needs.

Choice B rationale:

Reviewing the use of an artificial larynx with the client is the priority. Total laryngectomy involves the removal of the larynx, affecting speech. Providing information on alternative methods of communication, such as an artificial larynx, is crucial before the surgery.

Choice C rationale:

Determining the client's reading ability is relevant but does not take precedence over preparing the client for immediate postoperative communication.

Choice D rationale:

Explaining the techniques of esophageal speech can be part of the client education but is not the priority before addressing the immediate need for communication.

Choice A rationale:

Administering the PN and fat emulsion separately is not necessary; they can be combined into one solution for administration.

Choice B rationale:

Preparing the client for a central venous line is appropriate when administering parenteral nutrition (PN) with a high dextrose concentration and fat emulsions. A central venous line is typically used for PN with higher osmolarity.

Choice Crationale:

Obtaining a random blood glucose daily is important for monitoring the client's response to PN but does not address the initial plan of care.

Choice Drationale:

Changing the PN infusion bag every 48 hours is not a standard practice. The frequency of bag changes should follow the facility's policy and the product manufacturer's guidelines.

Choice A rationale:

Drinking a cup of hot cocoa before bedtime may contain caffeine, which can interfere with sleep.

Choice B rationale:

Taking a 30-minute nap daily, especially close to bedtime, may interfere with nighttime sleep.

Choice C rationale:

Exercising 1 hour before bedtime is generally not recommended as it can increase alertness and may disrupt sleep.

Choice D rationale:

Eating a light carbohydrate snack before bedtime is an appropriate intervention for promoting sleep. Carbohydrates can increase the availability of tryptophan, an amino acid that promotes sleep.

Choice A rationale:

The client seeking family approval by agreeing to a teaching plan may not necessarily lead to increased motivation for learning.

Choice B rationale:

The nurse's empathy about the client having to self-inject is important for building rapport but may not directly increase motivation for learning.

Choice C rationale:

The client's belief that his needs will be met through education is most likely to increase motivation to learn. Motivation is often higher when individuals see the value and relevance of the information to their personal needs.

Choice D rationale:

The nurse explaining the need for education to the client is the nurse's responsibility but does not address the client's intrinsic motivation.

Choice A rationale:

Palpating the abdomen should be done cautiously and is not the first action, especially if an abdominal obstruction is suspected.

Choice B rationale:

Auscultating bowel sounds is the first action the nurse should take when assessing a client with right lower quadrant pain, nausea, and vomiting. Bowel sounds can provide information about bowel motility and potential obstruction. The nurse should use the least invasive assessment technique first, which is auscultation.

Choice C rationale:

Administering an antiemetic may be necessary, but assessing bowel sounds takes precedence in the initial assessment.

Choice D rationale:

Offering pain medication is not the first action, as the cause of the symptoms needs to be identified before pain management. Pain medication could mask the symptoms and delay diagnosis.